Improving the Incident Reporting Process: Our Experience Moving Paper to Intranet

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• Improving the Incident Reporting Process Our
  Experience Moving Paper to Intranet
• Angela Ebel, RN, MSN
• Childrens Hospital of The Kings Daughters
• Patient Safety Fellow, Virginia Commonwealth
  University

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The Paper System

• Process was slow long TAT to resolution of
  issues
• Reported data was often incomplete and/or
  illegible
• Routing varied between departments
• Used interoffice mail system
• No near-miss data collection was built in
• No contributing factors cues were provided
• A separate database for prescribing and
  dispensing errors was being maintained by
  Pharmacy
• ADRs were being reported four different ways in
  two non-communicating databases
• Incident data being entered into software,
  limited report output available
• No ability to classify by potential risk only
  actual harm

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The Ideal System

• Easy for the employee to access, understand, and
  complete
• Fast understanding of specific incident issues
• Fast reporting of data trends to departments
• Fast reporting of incidents to the PI Dept and RM
• One database for all incidents
• Capture of near-miss events, contributing
  factors, and employee suggestions for improvement
• Ability to prioritize incidents and near-misses
  using a Hazard Score
• Improved accuracy of information provided
• Voluntary and confidential
• Allows for way to provide near-miss tips to other
  employees
• Low cost!

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System Selection

• Committee opted for a computerized online system
  of incident reporting
• CIO required that the database be in-house
• Choices left were network software or web-based
  software launched from our intranet connected to
  a local database
• Looked at Midas, QMS, custom software designed
  company, and others
• Our IS Dept convinced us that they could do the
  project.
• Wrote up a formal RFP with specific details
• Approved and work started almost immediately

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Software Design Process

• Decided to first complete online medication
  incident reporting all the way through the
  software design
• Online reporting of all other incidences would go
  to a hardcopy form and be handled in the old
  way
• Once medication incident reporting section live
  would then invisibly incorporate more types of
  incidents into the software
• Design process using The Wall method
• Converting to IS-ese
• Launches from our firewall protected intranet
• SQL server database
• System divided into Incident Reporter, Incident
  Reviewer, PI Classifications, Reports, Security
  and then the old way
• From start to live 10 months

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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reporter
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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Incident Reviewer
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PI Classifications
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PI Classifications
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24/48 Hour Quick Reports
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Trend Reports
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Trend Reports
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Trend Reports
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Security
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Security
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Security
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Using the Data

• Will be using a laptop with internet connection
  to run reports during Medication Safety Committee
  meetings.
• Will be trending prescribing errors by how they
  enter the organization. This will help to target
  areas for improvement since CPOE is not in the
  near future for our organization.
• Will be analyzing reported error and near-miss
  events for trends and possible systems
  improvements. Also trending contributing factors
  and reviewing employee suggestions for
  improvement.
• Should improve communication of incidents
  throughout the organization.
• Should automate the entire reporting process. We
  anticipate a decrease in the number of incidents
  reported initially and we will monitor this
  closely.
• Next will proceed to add more types of incidents
  to the software including specimen labeling
  errors, slips/falls, injuries, etc.